United States Government Accountability Office

GAO Report to the Committee on Indian 

Affairs, U.S. Senate 

INDIAN HEALTH 

SERVICE 

Health Care Services 

Are Not Always 

Available to Native 

Americans 

August 2005 

 

GAO-05-789 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

www.gao.gov/cgi-bin/getrpt?GAO-05-789.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Leslie Aronovitz 

at (312) 220-7600 or aronovitzl@gao.gov. 

Highlights of GAO-05-789, a report to the 

Committee on Indian Affairs, U.S. Senate 

August 2005

INDIAN HEALTH SERVICE 

Health Care Services Are Not Always 

Available to Native Americans 

The availability of primary care—medical, dental, and vision—services was 

largely dependent on the extent to which Native Americans living in IHS 

areas were able to gain access to the services offered at IHS-funded 

facilities. All of the 13 facilities GAO visited offered medical services, such 

as physical examinations, while 12 facilities offered dental and 12 facilities 

offered vision services. However, access to these services was not always 

assured because of factors such as the amount of waiting time between the 

call to make an appointment and the delivery of a service, travel distances to 

facilities, or a lack of transportation. 

Certain ancillary and specialty services were not always available to the 

Native Americans served by the 13 facilities, primarily because of gaps in the 

services offered by the facilities. While some ancillary and specialty services 

were offered to all patients, GAO also identified gaps in other services, 

including services to diagnose and treat nonurgent conditions—such as 

arthritis and knee injuries—specialty dental care, and behavioral health care. 

Most facilities lacked the staff or equipment to offer these services on site 

and thus had to purchase them with contract care funds, which were 

rationed on the basis of relative medical need at 12 of the 13 facilities. Five 

of the 12 facilities were unable to pay for any contract care services that 

were not deemed emergent or acutely urgent. 

GAO identified three distinct factors that were associated with variations in 

the availability of services, namely a facility’s structure, location, and 

funding from sources other than IHS. A facility’s structure was associated 

with the overall amount and range of services available. For example, 

hospitals offered a broader array of services on site for more hours per week 

compared with other facilities. Location was a factor in recruiting and 

retaining staff for geographically remote facilities and in the cost of certain 

types of services, most notably transportation. Finally, a facility’s funding 

from two types of sources—reimbursements from private and federal health 

insurance programs for care offered on site and any tribal contributions 

made—affected the extent to which the facility was able to offer services. 

The amount of these funds varied across facilities. 

Facilities reported using at least one of six strategies to increase the 

availability of services. These strategies included bringing specialists on site 

and negotiating discounts for contract care. According to officials, the 

strategies were not available to, or effective for, every facility. For example, 

four facilities reported that while hospitals generally offered discounted 

rates for contract care, physicians were not always willing to do so. 

The Indian Health Service (IHS), 

located within the Department of 

Health and Human Services, is 

responsible for arranging health 

care services for Native Americans 

(American Indians and Alaska 

Natives). IHS services include 

primary care (medical, dental, and 

vision); ancillary services, such as 

laboratory and pharmacy; and 

specialty care, including services 

provided by physician specialists. 

IHS provides some services 

through direct care at hospitals, 

health centers, and health stations, 

which may be federally or tribally 

operated. When services are not 

available—that is, both offered and 

accessible—on site, IHS offers 

them, as funds permit, through 

contract care furnished by outside 

providers. Concerns persist that 

some Native Americans are 

experiencing gaps in necessary 

health care. 

GAO was asked to examine the 

availability of (1) primary care 

services and (2) ancillary and 

specialty services for Native 

Americans. Additionally, GAO 

examined the underlying factors 

associated with variations in the 

availability of services and 

strategies used by facilities to 

increase service availability. GAO 

conducted site visits to 13 facilities 

and interviewed IHS officials from 

all 12 IHS areas, which cover all or 

part of 35 states. 

GAO received written comments 

from IHS. IHS substantially agreed 

with the findings and conclusions 

of this report. 
Contents 

Letter 1

Results in Brief 4 

Background 6

The Availability of Primary Care Depended on Native Americans’

Ability to Access Services at IHS-Funded Facilities 14 

Certain Ancillary and Specialty Services Were Generally Offered,

but Gaps in Other Services Were Common 17 

Factors Associated with Variations in Service Availability Included

Facility Structure, Location, and Funding 22 

Facilities Used a Variety of Strategies to Increase the Availability of

Services 29

Agency Comments and Our Evaluation 31 

Appendix I GAO Methodology for Selecting IHS Areas and 

Facilities Visited 33 

Appendix II GAO Methodology for Selecting Services 35 

Appendix III Comments from the Indian Health Service 39 

Appendix IV GAO Contact and Staff Acknowledgments 41 

Tables 

Table 1: Examples of Primary Care, Ancillary, and Specialty 

Services 10

Table 2: IHS Headquarters’ Guidance for Medical Priority Setting 

for Contract Care 13 

Table 3: Maximum Travel Distance to Services Offered by 10 

Facilities 17

Table 4: Ancillary and Specialty Services Offered by 11 or More of

the 13 IHS-Funded Facilities 18 

Table 5: Examples of Gaps in Ancillary and Specialty Services 19 

Table 6: Strategies to Increase Availability of Services Reported by 

13 IHS-Funded Facilities 29 

Page i GAO-05-789 Indian Health Service
Table 7: Description of How IHS-Funded Facilities Reported 

Implementing Strategies to Increase the Availability of 

Services 30

Table 8: Comparison of Three IHS Areas Selected by GAO to the 

Range across All 12 Areas 33 

Table 9: Characteristics of 13 IHS-Funded Facilities Selected for 

Site Visits 34 

Table 10: Patient Condition and Services Selected, as of May 2005 36 

Figures 

Figure 1: Key Differences in Health Status Indicators for Native 

Americans in IHS Areas and the U.S. General Population 7 

Figure 2: Counties in the 12 IHS Areas 8 

Figure 3: Overview of Eligibility Requirements for Contract Care 12 

Figure 4: Average Number of Services Offered on Site by Type of

Facility 23

Figure 5: Reimbursements as a Percentage of Total Direct Medical 

Care Budgets, Fiscal Year 2004 27 

Abbreviations 

CT computerized tomography

IHS Indian Health Service 

MRI magnetic resonance imaging 

Ob/gyn obstetrics/gynecology 

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Page ii GAO-05-789 Indian Health Service
United States Government Accountability Office

Washington, DC 20548 

August 31, 2005 

The Honorable John S. McCain

Chairman 

The Honorable Byron L. Dorgan 

Vice-Chairman 

Committee on Indian Affairs 

United States Senate 

Native Americans—American Indians and Alaska Natives—have

historically had poorer health than the U.S. general population, as 

evidenced by their higher incidence of certain medical conditions and 

their shorter average life spans.1

 In 1976, the Indian Health Care 

Improvement Act sought to raise the health status of Native Americans 

through increased funding and personnel for the Indian Health Service 

(IHS).2

 This agency, located within the Department of Health and Human 

Services, arranges the provision of health care services for Native

Americans across 12 federally designated areas that cover all or part of 

35 states. For fiscal year 2005, the Congress appropriated approximately 

$2.6 billion for health care services to be made available through IHS, 

which included primary care services (medical, dental, and vision); 

ancillary services, including laboratory, diagnostic imaging, and pharmacy 

services; and specialty care, including services provided by cardiologists, 

surgeons, and other physician specialists. Primary care, ancillary, and 

specialty services are offered through a combination of direct care, which 

is provided on site at IHS-funded facilities, and care purchased from other 

public and private providers—referred to here as “contract care.”3

IHS-funded facilities have varied in the health care services they have 

provided for Native Americans, and in some cases this has adversely 

affected the ability of Native Americans to obtain needed services. Our 

prior work identified issues regarding the availability of services for Native 

Americans, particularly services to meet the need for substance abuse 

 1

In this report, we use the term Native Americans to refer to American Indians and Alaska

Natives. IHS typically refers to this population as AI/AN or Indians.

2

Pub. L. No. 94-437, 90 Stat. 1400 (1976). 

3

IHS refers to contract care as contract health services or CHS. 

Page 1 GAO-05-789 Indian Health Service
treatment.4

 There remain concerns about the extent to which health care 

services are available—that is, both offered and accessible—to Native

Americans served by IHS.

5

You asked us to examine the health care services—both direct and 

contract care—that are available to Native Americans through IHS. We 

examined (1) the extent to which primary care services were available to 

Native Americans, (2) the extent to which ancillary and specialty services 

were available to Native Americans, (3) the underlying factors associated 

with variations in service availability among IHS-funded facilities, and 

(4) strategies used by IHS-funded facilities to increase the availability of

services. 

To perform our work, we conducted site visits in three IHS areas in

October and November 2004.6

 Our site visits included interviews with 

officials at 13 IHS-funded facilities (4 hospitals, 8 health centers, and 

1 health station7

), 8 of which were federally operated and 5 of which were 

tribally operated. We also interviewed representatives of health systems, 

hospitals, and physician groups that deliver contract care services and 

representatives of the tribes served by the facilities. The areas and 

facilities were selected to represent a mix in terms of size of patient

population, geographic location, type of facility, size of contract care 

budget, whether the facilities were federally or tribally operated, and 

health status of Native Americans in that area. (See app. I for a more

detailed description of our selection criteria.) To supplement the 

information collected on the site visits, we conducted follow-up interviews

with officials at the 13 facilities about the availability of specific services 

 i t

i i

i

4

See GAO, Indian Health Service: Basic Serv ces Mostly Available; Subs ance Abuse 

Problems Need Attention, GAO/HRD-93-48 (Washington, D.C.: Apr. 9, 1993). 

5

See U.S. Commission on Civil Rights, Broken Promises: Evaluat ng the Nat ve American 

Health Care System (Washington, D.C.: September 2004), and U.S. Department of Health

and Human Services, Agency for Healthcare Research and Quality, Nat onal Healthcare 

Disparities Report (Rockville, Md.: July 2003). 

6

The three areas we visited were (1) Aberdeen, which includes locations in South Dakota,

North Dakota, Nebraska, Iowa, and Minnesota; (2) Oklahoma City, which includes

locations in Oklahoma, Kansas, Nebraska, and Texas; and (3) Portland, which includes

locations in Idaho, Oregon, Utah, and Washington. 

7

Health centers are facilities with a full range of ambulatory services, including at least

primary care, nursing, pharmacy, laboratory, and X-ray, which are available at least 40

hours a week for outpatient care. Health stations offer primary care services on a regularly 

scheduled basis for less than 40 hours a week.

Page 2 GAO-05-789 Indian Health Service
for health conditions prevalent among the populations served by the 

facilities. Of these services, we analyzed the availability of 9 primary care 

services, 32 ancillary services, and 30 specialty services. (See app. II for a 

list of the services.) Findings pertaining to the 13 facilities we visited

cannot be generalized to all IHS facilities.

To assess the availability of services, we considered both whether the 

service was offered and whether it was accessible to individuals in the 

facility’s coverage area. We considered a health care service to be offered 

if a facility (1) delivered the service on site, (2) referred patients to another

IHS-funded facility in the vicinity for the service, or (3) provided the 

service through contract care regardless of the acuity of the patient’s 

condition. Services that did not meet one or more of these three criteria—

including services that were offered to some, but not all, patients—we 

considered to be gaps in services. To assess the accessibility of services, 

we considered (1) the length of time between the call to make an 

appointment and the delivery of a service, (2) the travel distances to 

facilities, and (3) the amount of time spent waiting at a facility for services. 

We corroborated information obtained in interviews by drawing on our 

observations of facilities and on documentation, such as policy and budget

documents, collected during the site visits. We also interviewed IHS area

officials about how service availability varied within each of the 12 IHS 

areas, what factors were associated with those variations, and what

strategies were being used to improve service availability. We drew on 

data from IHS area offices and headquarters related to funding, patient

volume, and health status of Native Americans living in these areas.8

 To 

assess the reliability of these data, we interviewed knowledgeable agency

officials and reviewed supporting documentation about procedures for 

collecting, analyzing, and compiling the information. We also consulted

experts at the Centers for Disease Control and Prevention about the health

status data, which IHS publishes regularly. In all cases, we determined that

the data were sufficiently reliable for purposes of this report. We 

conducted our work from August 2004 though June 2005 in accordance 

with generally accepted government auditing standards. 

 8

We reviewed funding data from fiscal years 2003 and 2004, patient volume data from fiscal 

years 2003 and 2004, and health status data from 1996 to 2001. 

Page 3 GAO-05-789 Indian Health Service
The availability of primary care—medical, dental, and vision—services 

largely depended on the extent to which Native Americans were able to

gain access to the services offered at the 13 IHS-funded facilities we

visited. Overall, we found that the facilities generally offered primary care 

services, with all 13 facilities offering medical services, such as physical 

examinations, and 12 facilities offering dental services, such as oral

examinations. Additionally, 12 of the 13 facilities offered vision care. 

However, access to these services was not always assured because of 

factors such as the amount of waiting time between the call to make an 

appointment and the delivery of a service, travel distances to facilities, or a

lack of transportation. For example, waiting times at 4 IHS-funded 

facilities ranged from 2 to 6 months for certain types of appointments, and

3 IHS-funded facilities reported that some Native Americans were required

to travel over 90 miles one way to obtain care. Facility officials noted that

difficulties accessing primary care services could result in an outcome 

such as inadequate prenatal care. 

Results in Brief

Certain ancillary and specialty services were not always available to 

Native Americans, primarily due to gaps in services offered. Certain 

ancillary services, such as laboratory and X-ray services, and specialty

services, such as obstetrics/gynecology (Ob/gyn) and outpatient mental

health, were generally offered to Native Americans. However, we

identified gaps in services to diagnose and treat nonurgent conditions, 

such as arthritis, knee injuries, and chronic pain. We also found gaps in

specialty dental care and behavioral health care. Most facilities did not

have the staff or equipment to offer certain services on site and thus had to

purchase these services through contract care. However, contract care

was not available in all cases because care was rationed on the basis of

relative medical need at 12 of the 13 facilities. Facility officials reported 

that in some cases gaps in services resulted in diagnosis or treatment

delays that exacerbated the severity of a patient’s condition and created a 

need for more intensive treatment. They also noted that gaps in such 

specialty services as orthopedics and behavioral health care meant that 

some Native Americans were living with debilitating conditions. 

We identified three distinct factors that were associated with variations in 

the availability of services, namely a facility’s structure, location, and 

funding from sources other than IHS. 

• A facility’s structure was associated with the amount and range of services

available. For example, the broader array of on-site services at hospitals 

compared with health centers increased the overall availability of services. 

Additionally, the five new facilities—those with buildings constructed 

Page 4 GAO-05-789 Indian Health Service
after 1990—had more space to offer additional types of services to more 

patients than did the eight older facilities. 

• A facility’s location was associated with its ability to recruit and retain 

staff and control the costs of providing health care services, which 

influenced the range of services offered as well as their accessibility. The 

more geographically remote facilities we visited faced the most significant 

challenges recruiting and retaining health care workers, as well as 

increased transportation costs for care needed but unavailable at the 

facility. 

• A facility’s funding from two types of sources, specifically 

(1) reimbursements from private health insurance and federal health

insurance programs for on-site services and (2) tribal contributions, 

affected the extent to which the facility was able to offer services. The 

amount of funding from these two sources varied among facilities. For

example, reimbursements ranged from less than 10 percent of direct

medical care budgets to more than 50 percent among the 12 facilities 

providing budget information. 

Officials at the 13 facilities we visited reported having implemented at 

least one of six strategies to increase the availability of services. The 

strategies most commonly implemented—cited by 9 or more of the 13 

facilities—were (1) bringing specialists on site, (2) improving efforts to

obtain reimbursements on behalf of patients who qualify for private health

insurance or federal health insurance programs, and (3) implementing 

prevention and wellness programs aimed at improving the overall health 

care outcomes of Native Americans. Facilities implemented these 

strategies through a variety of efforts. For example, facilities used contract

care funds to bring specialists to the facilities and shared medical staff 

with other IHS-funded facilities. 

We received written comments from IHS. IHS substantially agreed with

the findings and conclusions of our report, but did offer comments

regarding examples used in our report, as well as comments about 

terminology and other technical issues. We incorporated information 

provided by IHS as appropriate. IHS’s comments are reprinted in appendix 

III. 

Page 5 GAO-05-789 Indian Health Service
Native Americans living in IHS areas have lower life expectancies than the 

U.S. population as a whole and face considerably higher mortality rates for 

some conditions.9

 For Native Americans ages 15 to 44 living in those areas, 

mortality rates are more than twice those of the general population. Native

Americans living in IHS areas have substantially higher rates for diseases 

such as diabetes. Fatal accidents, suicide, and homicide are also more

common among them. Mortality rates for some leading causes of death—

such as heart disease, cancer, and chronic lower respiratory diseases—are

nearly the same for these Native Americans as for the general population. 

However, these Native Americans also have substantially lower rates of

mortality for other conditions, such as Alzheimer’s disease (see fig. 1 for a

summary of key differences in health status indicators between the two 

groups). 

Background 

 9

From 1996 through 1998, the life expectancy for Native Americans living in IHS areas was

70.6 years, compared with 76.5 years for the U.S. population as a whole. 

Page 6 GAO-05-789 Indian Health Service
Figure 1: Key Differences in Health Status Indicators for Native Americans in IHS Areas and the U.S. General Population 

Age-adjusted mortality rates, all ages

Number

Native Americans in IHS areas (1999-2001)

U.S. general population (2000)

0 10 20 30 40 50 60 70 80 90 100

Birth (per 1,000 population)

Low birth weight 

(per 100 live births)

Infant mortality

(per 1,000 live births)

 

 

 

Unintentional injuries

Tuberculosis

Suicide

Pneumonia and influenza

Nephritis, nephrotic

 syndrome, and nephrosis

Homicide 

Diabetes mellitus

Chronic liver disease

and cirrhosis

Cervical cancer

Breast cancer

Alzheimer's disease

Number of deaths per 100,000 population

0 10 20 30 40 50 60 70 80 90 100

Natality and infant mortality rates

Source: GAO analysis of IHS data, June 2005.

Notes: Mortality rates for Native Americans (American Indians and Alaska Natives) in IHS areas are

adjusted to compensate for misreporting of race on state death certificates. Mortality rates for Native

Americans in IHS areas and the U.S. general population are based on the 2000 U.S. Census 

Populations with Bridged Race Categories. Age-adjusted rates have been standardized to the 2000 

population. The age-adjusted mortality rate for all causes for Native Americans in IHS areas was

1059.8, compared with 872 for the U.S. general population. We investigated the possibility of

comparing mortality rates for Native Americans in IHS areas with mortality rates for Native Americans

nationwide but concluded that the nationwide data were not reliable.

IHS Administration In 2004, IHS estimated that its patient population was approximately 

1.4 million Native Americans. Area offices oversee the delivery of services

and provide guidance and technical support to the area’s facilities. The 12

IHS areas include all or part of 35 states (see fig. 2 for a map of the 

counties included in the 12 areas). 

Page 7 GAO-05-789 Indian Health Service
Figure 2: Counties in the 12 IHS Areas 

Nashville

Bemidji

Oklahoma City

Aberdeen

Counties in both California and Phoenix

Counties in both Phoenix and Tuscson

Counties in both Phoenix and Navajo

Counties in both Navajo and Albuquerque

Billings

Albuquerque

Navajo

Tucson

Phoenix

Portland

California

Alaska

Source: GAO analysis of IHS information, as of June 2005.

Note: IHS refers to the counties highlighted in this map as contract health service delivery areas.

Residence in these counties is generally one of the prerequisites for obtaining contract care services

through IHS, while eligibility requirements for direct care services—services provided at an IHSfunded facility—are broader.

Page 8 GAO-05-789 Indian Health Service
Within the 12 areas, direct care services are generally delivered through 

IHS-funded hospitals, health centers, and health stations. As of October 

2001, which is the most recent year of available data, there were 413 such 

facilities. These included 49 hospitals that ranged in size from 4 to 156 

beds. Nineteen of these hospitals had operating rooms. There were 231 

health centers and 133 health stations. These two types of facilities vary in 

the scope of their services and in their hours of operation. Health centers

offer a range of care, including primary care services and at least some 

ancillary services, such as pharmacy, laboratory, and X-ray, at least 40 

hours a week. Health stations offer primary care services and are open 

fewer than 40 hours a week. 

Services not available through direct care may be purchased through

contracts with outside providers. In most cases, the facility that provides a 

patient’s direct care services also authorizes payment for contract care

services. The use of contract care services varies considerably. For 

example, in two areas (California and Portland) all hospital-based services 

are purchased through contract care. In the other 10 areas, some hospitalbased services are provided at IHS-funded facilities, while others are 

purchased through contract care. 

Tribes have the option of operating their own direct care facilities and 

contract care programs. As of October 2001, tribes were operating 

27 percent of the 49 hospitals and 70 percent of the 364 health centers and 

health stations. The remaining facilities were federally operated. For fiscal

year 2005, approximately 50 percent of the IHS budget was allocated to 

tribes to deliver services.

Services Funded by IHS IHS funds a range of health care services for Native Americans. These 

services can be organized into three broad categories: primary care, 

ancillary, and specialty services. Table 1 shows these three categories, as 

well as the subcategories of services (for example, laboratory and 

pathology services) within each. The table also provides examples of

specific services, whose availability may vary among IHS-funded facilities. 

Page 9 GAO-05-789 Indian Health Service
Table 1: Examples of Primary Care, Ancillary, and Specialty Services 

Primary care services Ancillary services Specialty services 

Medical care 

• Evaluation and 

management of patient 

conditions performed by

midlevel practitioners 

(such as nurse 

practitioners or physician 

assistants) or physicians 

with primary care 

specialties 

Laboratory and pathology

services

• Screenings for cancer, 

tuberculosis, and 

elevated blood glucose 

• Initial assessments for 

diabetes and pregnancy 

Medical care 

• Ob/gyn, podiatry, 

nephrology, and other

services provided by

physician specialists 

Dental care

• Oral examinations, 

cleaning, sealants, and 

amalgam restorations 

Diagnostic imaging and

testing 

• X-ray, mammography,

amniocentesis, 

computerized 

tomography (CT), and

echocardiography 

Dental care

• Root canals, crowns, 

dentures, and periodontal

surgery 

Vision care 

• Eye examinations and 

prescriptions for vision 

correction 

Pharmacy Vision care 

• Diabetic eye 

examinations and 

cataract surgery 

Durable medical equipment

and adaptive devices 

• Knee braces, canes, 

wheelchairs, and 

eyeglasses 

Behavioral health care

• Outpatient and inpatient 

mental health care and 

substance abuse 

treatment services 

Emergency medical

transportation 

Rehabilitative services

• Physical therapy 

Source: GAO analysis of clinical standards published by IHS, medical associations, and other public entities, as of June 2005. 

Primary care services constitute the first level of health care and are 

generally the entry point for all other services. Ancillary services can be 

ordered by either a primary care provider or a specialist. For example, a 

blood test can be ordered by a primary care provider for an initial health

assessment or by an oncologist to test for recurrence of cancer. Specialty

services constitute a second level of care and generally address conditions

of higher acuity than those addressed by primary care. 

Page 10 GAO-05-789 Indian Health Service
Eligibility requirements for direct care and contract care differ. In general, 

all persons of Native American descent who belong to the Native 

American community are eligible for direct care at IHS-funded facilities.

10

To be eligible for contract care, a Native American generally must also 

reside within a federally established contract care area and either 

(1) reside on a reservation within the area or (2) belong to or maintain 

close economic and social ties with a tribe based on such a reservation.11

In most cases, a contract care area consists of the county or counties in

which a reservation is located, as well as any counties it borders.12

Contract care pays for services only when patients are unable to obtain 

such services through other sources, including Medicare, Medicaid, or

private insurance (fig. 3 provides an overview of the eligibility 

requirements for contract care). 

Eligibility Requirements 

for Direct and Contract 

Care 

 10Under IHS regulations, an individual is eligible for direct care if he or she is regarded as a

Native American by the community in which he or she lives, as evidenced by factors such 

as tribal membership, enrollment, residence on tax-exempt land, ownership of restricted 

property, active participation in tribal affairs, or other relevant factors. Non-Native 

Americans may in certain very limited circumstances also be eligible for direct care

services. 42 C.F.R. § 136.12 (2004).

11IHS refers to contract care areas as contract health service delivery areas or CHSDAs. 

12In three states—Alaska, Nevada, and Oklahoma—the contract care area covers the entire

state. 

Page 11 GAO-05-789 Indian Health Service
Figure 3: Overview of Eligibility Requirements for Contract Care

No

▼

No

▼

No

▼

Source: GAO.

Person cannot receive

contract care.

Is the person of Native American descent and a member of the Native American community?

Does the person live in the required area?

Does the person lack other health insurance 

coverage for the needed care?

Does the service meet the medical priority 

criteria set by IHS or the tribe?

Person can receive

contract 

care.

Yes

▼

Yes

▼

Yes

▼

Yes

▼

No

▼

Note: This figure represents GAO’s analysis of IHS regulations, which can be found at 42 C.F.R. §§

136.23, 136.61 (2004).

The services for which IHS provides contract care must also meet medical

priority criteria. Each IHS area office is required to establish medical 

priorities consistent with guidance published by IHS headquarters (see 

table 2 for an overview of the guidance). Federally operated facilities must

abide by the priorities set by their respective area offices, assign a priority

level to each service requested, and fund services in order of priority, as

funds permit. Although federally operated facilities are required to pay for

all priority I services (emergent/acutely urgent care), facilities may 

otherwise pay for all or only some of the services in the lowest priority

level they fund.13 Tribally operated facilities have discretion in setting 

medical priorities. While these facilities must have a priority setting 

 13In commenting on our report, IHS explained that although federally operated facilities are

required to pay for all priority I services, if available funds at a facility are expended before

the end of the fiscal year, or if a facility has insufficient funds to pay for all priority I cases,

payment is not made. IHS further explained that this is the case at many of its facilities. 

Page 12 GAO-05-789 Indian Health Service
system, they may develop a system that differs from the guidance 

established by IHS. 

Table 2: IHS Headquarters’ Guidance for Medical Priority Setting for Contract Care

Priority level Examples of services 

I. Emergent/acutely urgent care Trauma care, acute/chronic renal dialysis, obstetrical 

delivery, neonatal care, emergency psychiatric care

II. Preventive care Preventive ambulatory care, prenatal care, screening 

mammograms, public health intervention

III. Primary and secondary care Scheduled ambulatory services for nonemergent 

conditions, elective surgeries, specialty consultation 

IV. Chronic tertiary and extended 

 care 

Rehabilitation care, skilled nursing home care, highly 

specialized medical care, organ transplant 

V. Excluded care Cosmetic and experimental services, services with 

no proven medical benefit 

Source: GAO analysis of IHS 2004 guidance.

In addition to meeting eligibility and medical priority requirements, Native 

Americans must meet certain procedural requirements for services to be 

paid for through contract care. In particular, individuals who obtain 

emergency services generally must notify IHS within 72 hours of obtaining 

the services.14 IHS headquarters data on denials of payment for contract

care are incomplete.15 However, in fiscal year 2003, patients’ or providers’

failure to comply with two procedural requirements (72-hour notification 

of emergency services and prior approval of nonemergency services) 

accounted for at least 16 percent of all reported denials of payment for 

contract care nationwide. 

 14Notification may be made by someone acting on the patient’s behalf. Some categories of 

individuals, such as elderly individuals, are exempt from the 72-hour notification

requirement. 

15Data are incomplete because not all tribally operated facilities report denial data to IHS

headquarters, and not all requests for care are documented at the facilities that do report.

Moreover, the number of denials of contract care ascribed to any particular reason for

denial (e.g., failure to notify IHS within 72 hours of emergency services) is also likely to be

an undercount because the data show only the primary reason for denial, and reasons are 

not necessarily ranked in the same way by different facilities.

Page 13 GAO-05-789 Indian Health Service
The $2.6 billion that the Congress appropriated for fiscal year 2005 for IHS 

included funds for direct care, as well as $505 million for contract care 

services.16 From the $2.6 billion, IHS also funds public health nursing, 

scholarships to health professionals, and other functions. In addition to

IHS’s federal appropriation, facilities are reimbursed for the services they 

provide on site by private health insurance and federal health programs, 

such as Medicare and Medicaid.17 IHS-funded facilities are allowed to

retain reimbursements from private and federal health programs, without

an offsetting reduction in their IHS funding, in order to fund health

services.18 In fiscal year 2004, IHS-funded facilities obtained approximately 

$628 million in reimbursements, with 92 percent collected from Medicare 

and Medicaid and 8 percent from private insurance.19

The availability of primary care—medical, dental, and vision—services 

largely depended on the extent to which Native Americans were able to

gain access to the services offered at IHS-funded facilities. The 13 facilities 

we visited generally offered primary care—medical, dental, and vision—

services; however, Native Americans’ access to these services was not 

always assured. Although primary care services were offered, facility and 

tribal officials identified several factors that affected access to these 

services, such as wait times between scheduling an appointment and 

receiving services, travel distances to facilities, and a lack of

transportation.

IHS Funding 

The Availability of 

Primary Care

Depended on Native 

Americans’ Ability to 

Access Services at 

IHS-Funded Facilities 

 16We included in contract care funding the $18 million appropriated by the Congress for the 

Catastrophic Health Emergency Fund, which distributes funds to facilities on a first-come, 

first-served basis for high-cost contract care cases.

17Medicare is a federal health insurance program for individuals aged 65 and older and for

some disabled adults. Medicaid is a jointly funded federal-state health care program that

covers certain low-income families and low-income individuals who are aged or disabled. 

18See 25 U.S.C. §§ 1621f, 1645 (2000). 

19These numbers include estimates of reimbursements from the Centers for Medicare &

Medicaid Services and from tribes. 

Page 14 GAO-05-789 Indian Health Service
All 13 facilities we visited offered medical services, such as initial physical 

examinations for pregnant women and well-baby checkups, while 12 

facilities offered dental services, such as oral examinations, cleanings, and

sealants.20 Twelve of 13 facilities offered vision care. 

Four facilities offered certain primary care services by making 

arrangements for patients to obtain these services at other locations, 

including other IHS-funded facilities. The arrangements facilities made for

care differed, depending on their relationships with other IHS-funded 

facilities, the nature of the service, and proximity to other facilities. For 

example, one clinic routinely referred patients needing eye examinations

to an IHS-funded hospital located about 50 miles away with which it had 

an ongoing relationship. Another facility provided dental services on site

to children, pregnant women, and adults with diabetes, while referring all 

others seeking dental care to other IHS-funded facilities. For vision 

services, this facility directed patients to a different facility that offered

eye examinations for children and adults. Another facility purchased 

primary care services from private providers for Native Americans who 

lived 75 miles from that facility. 

At over half of the facilities we visited, facility officials indicated that 

patients were able to obtain certain primary care services—such as

physical examinations and well-baby checkups—often within 3 weeks of

calling for an appointment. However, the waiting times between calling for

an appointment and receiving services were considerably longer for other 

primary care services. For example, four facilities reported that patients

routinely had to wait more than a month for some types of primary care, 

which was in excess of standards or goals identified in other federally

operated health care service delivery systems.21 The wait times at the four

facilities ranged from 2 to 6 months, with the services cited as requiring

lengthy waits being women’s health care, general physicals, and dental 

care. 

Facilities Generally

Offered Primary Care

Services 

At Some Facilities, Access 

to Primary Care Was Not 

Assured due to Lengthy 

Waits for Certain Services

and Limited 

Transportation 

 20The remaining facility offered certain dental services, such as sealants and oral

examinations to children only, and cleanings to children, pregnant women, and adults with 

diabetes. 

21Under the Department of Veterans Affairs policy, veterans who have high priority for 

receipt of health care through the department are to be given nonurgent outpatient

appointments within 30 days of the desired date. The Department of Defense requires

health plans in its managed care program, TRICARE Prime, to schedule routine

appointments within 7 days and routine specialty care within 30 days. 

Page 15 GAO-05-789 Indian Health Service
In some cases, facility officials reported that the demand for services 

exceeded available appointment slots. For example, facility or tribal

officials at 7 of the 13 facilities cited a need to increase dental services in 

order to keep up with their populations’ demand. Additionally, three 

facilities indicated that medical care slots made available for same-day 

appointments were usually filled within 45 minutes of the phone lines

being opened.

22 At one of these facilities, 20 to 30 slots were usually filled 

within 15 to 30 minutes. An official at this facility estimated that it was

turning away 25 to 30 patients a day. Officials at 6 of the 13 facilities we

visited cited a need to increase the amount of primary care services to

meet demand in the service population. Some tribal officials remarked on 

the demoralizing effect on patients who had difficulty getting 

appointments. For example, one tribal official noted that rather than 

remain at the facility all day to see a provider, patients would wait to seek 

care until their condition became an emergency that required a higher 

level of treatment. Officials at another facility reported that 21 percent of

their maternity patients had three or fewer prenatal care visits, well below

the recommended number.23

Transportation challenges also affected the extent to which access to care 

was assured for some Native Americans. Of the 10 facilities that provided

information on their patient coverage areas—the greatest distance patients

traveled to the facility to obtain services—8 reported that some of their 

patients traveled 60 miles or more one way for care (see table 3). Of these 

8 facilities, 3 reported over 90 miles of travel one way to obtain care—a 

distance in excess of what IHS considers reasonable for primary care 

services.24

 

t

22Some facility officials said that they established same-day appointment systems in an

effort to make more daily appointments available or to respond to the number of missed

appointments for services scheduled in advance. 

23The American College of Obstetricians and Gynecologists recommends a minimum of 14

visits for a full-term (40-week) pregnancy with no complications. 

24As of June 2005, IHS’s Indian Heal h Manual indicates that for patients who are more than

90 minutes away, facilities may pay other providers to deliver primary care services. 

Page 16 GAO-05-789 Indian Health Service
Table 3: Maximum Travel Distance to Services Offered by 10 Facilities 

Maximum travel distance (in miles) Number of facilities

91 to 180 3

60 to 90 5

Under 60 2

Source: GAO analysis of facility information, as of June 2005. 

Two facilities reported having made other arrangements for patients to

obtain primary care when travel distances to facilities were particularly 

long. One facility used contract care funds to pay providers to deliver

primary care services to patients who were 75 miles from the facility until

funding constraints eliminated this option. Similarly, another facility paid

to deliver primary care services to patients more than 25 miles from the 

facility until funding constraints made it necessary to restrict this option to 

children and elders. 

Although long travel distances to reach health care facilities create access 

problems for rural populations in general, for some Native Americans, a 

lack of transportation compounded the difficulty of obtaining care.

Officials at 9 of the 13 facilities reported that transportation to reach

services was a challenge for certain tribal members, due in part to high 

rates of unemployment and the consequent inability of many members to 

afford a vehicle or pay for other transportation. While facility officials 

noted that some transportation programs were offered to tribal members, 

they did not reach all in need. For example, transportation services in two 

coverage areas were limited to groups such as the elderly, disabled, 

individuals experiencing medical emergencies, or members of a particular 

tribe. 

Certain ancillary and specialty services were not always available to 

Native Americans, primarily due to gaps in services offered at nearly all of 

the 13 facilities. We found that certain ancillary and specialty services 

were offered through direct or contract care by 11 or more of the 13

facilities we visited. However, although outpatient mental health care was 

offered by all 13 facilities, some reported that demand for services 

outstripped their capacity. We also identified gaps in certain ancillary and 

specialty services at the 13 facilities, including services to diagnose and 

treat conditions that were neither emergent nor acutely urgent. Most

facilities that did not offer the services on site lacked the funds to pay for 

them through contract care. 

Certain Ancillary and 

Specialty Services 

Were Generally 

Offered, but Gaps in 

Other Services Were 

Common 

Page 17 GAO-05-789 Indian Health Service
Certain ancillary services—laboratory, some diagnostic imaging and 

testing, pharmacy, and emergency medical transportation—were offered

through direct or contract care by 11 or more of the 13 facilities we visited. 

We also identified four specialty services that were offered by almost all of

the facilities (see table 4). In most cases, services were offered on site at

the facilities rather than through contract care. For example, 11 or more of

the 13 facilities we visited had a laboratory, pharmacy, X-ray machine, 

electrocardiograph, and mental health counselors on site.

25

Certain Ancillary and 

Specialty Services Were

Offered, but Access to 

Some of These Services 

Was Not Assured 

Table 4: Ancillary and Specialty Services Offered by 11 or More of the 13 IHSFunded Facilities 

Ancillary services Specialty services 

Laboratory and pathology services

• Preventive screenings, including 

tuberculosis and fasting glucose tests 

• Initial evaluations for pregnancy, 

diabetes, heart failure 

Medical care 

• Ob/gyn

Diagnostic imaging and testing

• X-ray, electrocardiography, 

mammography, amniocentesis, prenatal 

ultrasound 

Dental care

• Root canals 

Pharmacy Vision care

• Cataract surgery, retinopathy screening 

Emergency medical transportation Behavioral health care

• Outpatient mental health care and 

substance abuse treatment services 

Source: GAO analysis of facility information, as of June 2005. 

Although outpatient mental health care services were offered by all

facilities, four facilities reported that demand for mental health care 

outstripped their capacity. For example, one facility cited a need for two 

to three times the amount of psychiatric care it was able to offer. An 

official at another facility commented that the facility was able to provide 

only crisis-oriented care. Another facility reported that it expected to cut 

mental health services by 20 percent in fiscal year 2005, as reserves that

had previously supported these services had been depleted. 

 25At all eight of the federally operated facilities we visited, at least some behavioral health

services were operated by tribes rather than by the federal facilities. For purposes of this

report, we included these tribally operated services as being associated with the medical

facilities. 

Page 18 GAO-05-789 Indian Health Service
We found that gaps in ancillary and specialty services were common, 

occurring at 12 of the 13 facilities. The most frequent gaps were for 

services aimed at the diagnosis and treatment of medical conditions that

caused discomfort, pain, or some degree of disability but that were not

emergent or acutely urgent (see table 5). In some cases, services were 

offered to certain groups but not others. For example, four facilities

offered eyeglasses only to children or older adults.

26 In other cases, 

services were significantly delayed; for example, one facility said that

adults could wait as long as 120 days to get approval for eyeglasses. 

Gaps in Ancillary and 

Specialty Services Were

Common for Diagnosis and 

Treatment of Nonurgent 

Conditions 

Table 5: Examples of Gaps in Ancillary and Specialty Services 

Category of service 

Facilities 

reporting 

gaps Examples of specific gaps 

Specialty consultations for 

nonemergent or acutely urgent

cases 

11 Consultations for arthritis, acne, allergies, 

gastrointestinal ailments 

Specialty dental care 11 Orthodontics, cast inlays or crowns, 

dentures, periodontal surgery 

Treatment for chronic pain 11 Evaluation and treatment for back pain 

Durable medical equipment 

and adaptive devices 

11 Canes, braces, wheelchairs, prostheses, 

adjustable beds, lifts, eyeglasses 

Diagnostic imaging for 

nonemergent or acutely urgent

cases 

10 CT scans for chronic sinusitis, magnetic

resonance imaging (MRI) for knee 

injuries 

Elective surgery 10 Ear tube surgery, tonsillectomy, back

surgery, knee replacement 

Cancer screenings 7 Sigmoidoscopy or colonoscopy to screen 

for colon cancer 

Behavioral health care 6 Inpatient substance abuse treatment, 

inpatient mental health care

Source: GAO analysis of facility information, as of June 2005. 

Notes: Gaps were identified when a facility did not offer one or more services on site or through 

contact care or offered services only to some patients.

One facility we visited did not report any gaps in services.

 26One of these facilities, which offered eyeglasses to adults over age 55, stopped doing so in

2005. 

Page 19 GAO-05-789 Indian Health Service
We found significant gaps in both dental and inpatient behavioral health

care services offered at IHS-funded facilities or through contract care.

• Of the five specialty dental services we inquired about, three (cast inlays 

or crowns, dentures, and orthodontics) were entirely unavailable at most

of the facilities.27 Some facilities offered these services only to certain 

groups. For example, one facility offered cast inlays and crowns only to

children.

• Inpatient behavioral health care services were either not offered or 

limited. Six facilities did not offer inpatient mental health care treatment

to all patients. Four of these six facilities did not offer inpatient substance 

abuse treatment to all patients.28 Moreover, three of the nine facilities that

did offer inpatient substance abuse treatment offered only partial

services—rehabilitation but not detoxification.29

Most of the facilities we visited lacked the equipment necessary for certain 

ancillary services and had few medical specialists on site. Most lacked

such diagnostic equipment as mammography machines, CT scanners, MRI 

scanners, and echocardiographs. Ten facilities, including one hospital,

reported having three or fewer types of specialists on site.

30 Most facilities 

did not regularly refer patients to other IHS-funded facilities for care they

could not offer on site. 

Ancillary and specialty services that were unavailable on site or at other 

IHS-funded facilities could be obtained only through contract care, which 

was rationed by 12 of the 13 facilities on the basis of relative medical need. 

Five facilities reported that they were unable to pay for any services that

were not deemed emergent or acutely urgent (services categorized as 

priority level I services in IHS headquarters’ guidance), and two others

paid for only a few additional services, such as cancer screenings. The 

Facilities Lacked Staff,

Equipment, and Contract 

Care Funds to Offer 

Certain Ancillary and 

Specialty Services 

 27Root canals and periodontal surgery were offered by 11 and 7 facilities, respectively. 

28We defined inpatient treatment as treatment beyond an initial 72-hour stay. 

29One of the three facilities that did not offer detoxification noted that it could be obtained 

through a county-operated program.

30The medical specialty services most commonly reported on site at the 13 facilities were

podiatry and ob/gyn, which were offered at 9 and 7 facilities, respectively. Specialists

reported on site at few facilities included ear, nose, and throat specialists (4 facilities), 

orthopedists (3 facilities), nephrologists (3 facilities) and cardiac specialists 

(2 facilities). Two facilities reported having no specialists on site. 

Page 20 GAO-05-789 Indian Health Service
remaining six facilities paid for varying levels of care beyond the emergent

or acutely urgent level, but only one of the six was able to pay for all of the

care we inquired about (see app. II). 

Officials noted that in some cases gaps in services resulted in diagnosis or 

treatment delays that exacerbated the severity of a patient’s condition and 

created a need for more intensive treatment. For example, tribal health 

board members at one facility described the case of an elderly woman 

who had complained of back pain and was diagnosed with cancer only

when one of her legs broke. Tribal representatives at another facility cited 

the example of a young man whose lung condition was only properly 

diagnosed when, after months of treatment for pneumonia, he went to an 

emergency room and was found to have a tumor that killed him 3 weeks

later. Officials also noted that as a result of gaps in such specialty services 

as orthopedics and behavioral health care, some Native Americans were 

living with painful and debilitating conditions. 

Service gaps not only varied among facilities, but also varied over time for 

particular facilities, depending on the demand for contract care. Facility

officials said that demand for contract care could affect where they drew

the line between services that met medical priority criteria and those that 

did not.

31 For example, one facility reported that the definition of emergent 

and acutely urgent services narrowed over the course of the year as

contract care funds were depleted. At facilities that reviewed requests for 

contract care or budgeted for this care on a quarterly, monthly, or weekly

basis (as most did), approval of a particular service depended in part on its 

priority relative to the others that came up for review at the same time. 

In some cases, patients faced challenges accessing the care that was 

offered through contract care or at other IHS-funded facilities. At seven

facilities, patients had to travel more than 60 miles from the facility to

obtain some kinds of specialty care—for example, gastroenterology, 

cardiology, and high-risk obstetrics—that were available only in larger 

cities. Access also depended on non-IHS providers’ willingness to provide 

 31The process for determining the relative medical priority of services was similar at most 

facilities. Generally, clinicians assigned a priority level to each referral, based on their 

assessment of the acuity of the patient’s condition. These referrals were then reviewed by

other clinicians or administrators to determine whether the services requested were of a 

high enough priority to be paid for. Bills for services obtained without prior approval, such

as emergency room care, were also reviewed. Some facilities maintained lists of deferred 

services and reviewed them again as more funds became available. 

Page 21 GAO-05-789 Indian Health Service
contract care. Few of the IHS-funded facilities we visited mentioned 

difficulties arranging contract care. However, 10 of the 15 contract care

providers we interviewed, which included health systems, hospitals, and 

physician groups, reported denials or delays of payment by IHS, and some 

had terminated or were considering terminating their relationship with

IHS as a result. One obstetrician who was owed about $60,000 stopped 

seeing IHS patients until most of his outstanding bills were paid. Two 

providers were considering terminating their relationship with IHS-funded 

facilities. Two other providers reported that physicians in their system or 

in the area had closed their practices to IHS patients. In some cases, the 

withdrawal of a single provider may affect patients’ access to care. For 

example, staff of a physician specialty group that had threatened to stop 

serving IHS patients said that if it had done so, these patients would have

had to travel an additional 75 miles for care, as this group was the only

provider of its type in the vicinity that was willing to serve IHS patients. 

From our visits to facilities and interviews with IHS area officials, we 

found that differences in the availability of services among facilities were 

associated primarily with three distinct factors: how a facility was 

structured, where it was located, and the amount of reimbursements and 

tribal contributions it received. In terms of facility structure, we found 

differences in the amount and range of services available on site, 

depending on the type of facility (whether it was a hospital, health center, 

or health station), its age, and whether it was tribally or federally operated. 

Facilities located in remote areas faced challenges in recruiting and 

retaining staff, which reduced the services these facilities were able to 

offer. Those facilities that received greater amounts of funding from 

reimbursements or tribes were able to expand service availability by, for 

example, hiring additional staff.

From our visits to facilities, we found that the broader array of on-site

services at hospitals compared with health centers increased the overall 

availability of services32 (see fig. 4 for the services offered at the hospitals 

and health centers). While the average number of primary care services 

offered on site was the same at the hospitals and health centers, the 

average number of ancillary and specialty services offered on site differed.

Factors Associated 

with Variations in 

Service Availability 

Included Facility 

Structure, Location, 

and Funding 

Facility Structure Was 

Associated with Variations 

in Service Availability 

 32Of the services about which we inquired, the health station reported offering 3 of 9 

primary care services, 15 of 31 ancillary services, and 2 of 33 specialty services on site. 

Page 22 GAO-05-789 Indian Health Service
The hospitals generally offered more types of ancillary services on site—

such as mammography—than did the health centers. Three hospitals also 

offered some specialty services on site—such as some obstetric services—

that were not offered on site at the health centers we visited. IHS officials 

noted that its hospitals are located where service populations are large 

enough to make it professionally and financially possible to offer more 

services. 

Figure 4: Average Number of Services Offered on Site by Type of Facility 

0 10 20 30 40 50 60

 

 

 

Health centers (8)

 

Hospitals (4)

Source: GAO analysis of information from 13 IHS-funded facilities, as of June 2005.

Average number of primary care services offered on site

Average number of ancillary services offered on site 

Average number of specialty services offered on site

8

8 20 9

26 16

Number

Notes: This analysis summarizes information on 71 services—including 9 primary care services, 

32 ancillary services, and 30 specialty services—about which we inquired. We also visited one health

station, which reported providing 3 primary care services, 15 ancillary services, and 2 specialty

services. 

Services at hospitals were also offered for more hours per week than were

services at other facilities, which resulted in differences in the availability 

of urgent care. The hospitals had emergency rooms open 24 hours a day 

and 7 days a week and were available for urgent care services. In contrast, 

the health centers were generally open from 8:00 a.m. to no later than 

5:30 p.m., Monday through Friday. When the health centers were closed, 

urgent care was generally available at non-IHS facilities. Not all of the 

health centers paid for nonemergency services provided by these facilities.

We found that in general the five newer facilities—those with buildings 

constructed after 1990—had more space to offer additional types of 

services to more patients than did the eight older facilities. Officials from

the facilities we visited reported that the age of their building was linked 

Page 23 GAO-05-789 Indian Health Service
to building design, space, and resources, which affected both the range of

services facilities offered as well as Native Americans’ access to these 

services.33 For example, officials at two of the newer health centers

reported that they had more examination rooms than they had had in their 

old buildings, which allowed one facility to add new specialty providers,

see additional patients, and reduce wait times. According to an IHS 

headquarters official, prior to 1988, IHS-funded facilities were constructed 

with one examination room per primary care provider. From 1988 to early

2005, the standard number of examination rooms per provider for new

construction was two, and as of April 2005, the standard number was two 

and one half. In addition to the benefits of an improved design and more 

space, area officials explained that when new buildings are constructed 

with IHS funds, those facilities generally receive increased funds for staff

and equipment,

34 which allows the facilities to provide additional types of

services or serve more patients. 

In addition, the range of services facilities offered depended in part on 

whether the facilities we visited were tribally or federally operated.

35

Because tribally operated facilities are not required to follow the medical 

priorities established by IHS for contract care, tribally operated facilities

were able to make different judgments about the allocation of the funding.

For example, all of the three tribally operated health centers offered 

eyeglasses. In contrast, only one of the five federal health centers offered 

eyeglasses—and only to children. Another tribal facility offered some

nonemergency ancillary services, such as MRI scans for patients with

nonemergent conditions, such as seizures, while the federal facilities 

generally offered those services only to patients with emergent or acutely

urgent conditions. One tribal facility used its flexibility in setting medical 

priorities to deny certain care that federal facilities are required to offer. 

Specifically, this facility, which had an emergency room, did not pay for 

any emergency room services at outside facilities. In contrast, federal 

facilities are required to pay for emergency room services for patients who

require emergency care at a hospital that is not funded by IHS. 

 33The construction dates for the 13 facilities ranged from the 1930s to 2004. 

34In cases where IHS provides grant funds to a tribe for construction of a small facility, IHS 

does not provide funds for staff and equipment. 

35We visited five tribally operated facilities and eight federally operated facilities. 

Page 24 GAO-05-789 Indian Health Service
According to facility and area officials, flexibility in setting medical

priorities for contract care helped tribal facilities, especially those with 

smaller populations, manage available funds. One tribal hospital we visited 

reported that if the facility were required to offer emergency services 

through contract care, one catastrophic case could eliminate its entire 

contract care budget. According to officials, the facility had accrued 

$3.5 million in unpaid contract care bills when under federal operation. 

When the tribe took over operations in 1994, it paid portions of this debt

for 3 years. The tribe revised its medical priority system in part by 

restricting emergency care to what is available at the tribally operated 

facility and expanding coverage of contract care referrals for diagnostic 

services. In the California area, where all of the facilities are tribally 

operated and there are no IHS-funded hospitals, contract care budgets for 

small tribes were sometimes less than $40,000. Area officials reported that

facilities with budgets of that size may not guarantee that emergent and 

acutely urgent care, such as obstetrical deliveries, would be offered. 

Location Affected the 

Services Facilities Could 

Offer 

Of the 13 facilities we visited, 6 facilities were located in frontier counties

and 7 in less remote, nonfrontier counties.36 Officials from 5 of the 6 

facilities in frontier counties cited challenges in recruiting and retaining 

health care professionals, which affected the services these facilities could 

offer. Officials from 3 of these facilities reported that a shortage of housing 

for health care workers on the reservations and in nearby communities

contributed to the problem. Area officials added that facilities in isolated

areas also lacked educational and recreational opportunities for 

employees and their families. Facility officials reported such position 

vacancies as pharmacists, dentists, dental assistants, and X-ray and 

laboratory technicians. Some of these positions remained vacant for 

several years. For example, one facility reported that it had taken 8 years

to fill a dentist position that became vacant again in December 2004. 

Facilities located in remote areas also more frequently reported high 

transportation costs, particularly for emergency medical services, which 

decreased contract care funds for other services. For example, lacking the 

needed care on site, three of the six facilities located in remote counties 

reported having to transport patients by helicopter or airplane to other 

 36The Frontier Education Center designates a county as “frontier” based on a scoring

system that computes points based on a county’s population density, distance to the 

closest “market” for services, and travel time to that market. 

Page 25 GAO-05-789 Indian Health Service
facilities. Officials at one of those facilities reported paying for 17 to 21 air 

transports a month at a cost of $6,000 to $7,000 each, which was from 

17 percent to 24 percent of the facility’s fiscal year 2004 contract care 

budget. Another facility also told us that ambulance transport was a 

significant contract care cost. 

Service Availability Was 

Associated with the 

Amount of 

Reimbursements and 

Tribal Contributions 

Facilities Received 

At all of the 13 facilities we visited, reimbursements from private health 

insurance and federal health insurance programs, such as Medicare and 

Medicaid, were an important source of funding for the services each 

facility offered. We found that the amount of reimbursements that

facilities obtained varied. For the 12 facilities that provided budget 

information for fiscal year 2004, reimbursements constituted from

7 percent to 58 percent of direct medical care budgets, with the average 

being 39 percent (fig. 5 shows the proportion of facilities’ direct medical 

care budgets that came from reimbursements). Facilities with higher 

reimbursements had additional funds with which they could hire staff,

purchase equipment and supplies, and renovate their buildings. For 

example, a hospital that collected $14.7 million in reimbursements, 

representing 51 percent of its direct medical care budget, funded 

31 percent of its clinical providers and other staff (111 of 361 staff 

members) with those funds. 

Page 26 GAO-05-789 Indian Health Service
Figure 5: Reimbursements as a Percentage of Total Direct Medical Care Budgets, Fiscal Year 2004 

Hospitals

Source: GAO analysis of fiscal year 2004 budget data reported by 12 IHS-funded facilities.

Medicare as a percentage of direct medical care budget

Medicaid as a percentage of direct medical care budget

Private health insurance as a percentage of direct medical care budget 

0 10 20 30 40 50 60

12

Health station

11

10

9

8b

7

6a

5

Health centers

4

3

2

1 12

11

8

6

1

5

1

6

1

1

1

19

20

4

11

39

44

5

8

2 4

3 5

19 9

29

43

38

49

15

6

15

5

Percentage

18

Note: We defined budgets for direct medical care as IHS funds allocated for the operation of hospitals 

and clinics plus reimbursements from Medicare, Medicaid, and private health insurance.

a

This facility aggregated Medicare and Medicaid fee-for-service revenue. We classified this revenue 

under Medicare reimbursements.

b

These budget data reflect those of the health center that we visited as well as an associated IHSfunded health center.

Page 27 GAO-05-789 Indian Health Service
Facility officials reported that certain circumstances outside of their 

control affected their ability to obtain reimbursements. Specifically, these 

circumstances included changes in state Medicaid programs and the 

nature of the insurance offered by tribes. 

• Changes in state Medicaid programs. Medicaid was the largest source 

of reimbursements in 10 of the 12 facilities and on average accounted for 

65 percent of total reimbursements.

37 While the federal government

finances 100 percent of Medicaid services provided to Native Americans at

IHS-funded facilities, eligibility and benefits vary among states. Facility

officials provided examples of eligibility, benefit, and administrative

requirement changes that states have made in their Medicaid programs 

that have affected facilities’ ability to obtain reimbursements. For 

example, one state’s Medicaid program used to confer retroactive 

eligibility for a 3-month period; thus any service provided to a Medicaideligible person in the 3 months prior to their enrollment would be paid for 

by the Medicaid program. As of April 2003, however, the program has 

reduced retroactive eligibility to the beginning of the month in which 

eligibility was determined. 

• Nature of insurance offered by tribes. The nature of the insurance 

offered by different tribes affected the amount of reimbursements 

available to facilities. For example, four federally operated facilities 

provided services to tribes with self-insured health plans. Because 

federally operated IHS-funded facilities are prohibited by law from billing 

for services covered by self-insured plans offered by tribes,38 their 

reimbursements from private health insurance were limited. For example, 

private health insurance comprised less than 14 percent of total 

reimbursements for these four facilities. Three other facilities (two tribally

operated and one federally operated) that were able to bill tribal health

insurance reported collecting approximately 30 percent of total 

reimbursements from private health insurance. Officials at one federally 

operated facility also reported that reimbursements were lower when 

tribal employees chose not to participate in tribal health plans and instead 

relied entirely on IHS-funded care. 

 37According to IHS, facilities’ ability to obtain reimbursements from the Medicaid program

is strongly influenced by the percentage of their patients who meet the income

requirements for Medicaid coverage. 

38See 25 U.S.C. § 1621e(f) (2000). 

Page 28 GAO-05-789 Indian Health Service
In addition to reimbursements, contributions from tribes were a key 

source of funding for services, as 8 of the 13 facilities we visited reported 

obtaining tribal contributions. At 6 facilities, tribes supplemented care by 

providing funds for contract care, pharmaceuticals, and other operating 

costs. Other facilities benefited from onetime contributions. For example, 

two tribes used their own funds or obtained grants to build new facilities 

with additional examination and treatment space that allowed the facilities

to offer more services. In addition to direct contributions of funds, some

tribes obtained other funds to supplement IHS resources for services such 

as substance abuse treatment. Officials from 3 of the 8 federally operated 

facilities reported that tribes did not provide additional funding for 

services. 

Facilities reported having implemented at least one of six strategies to

increase the availability of services funded by IHS. The strategies most

commonly used by the 13 facilities we visited included bringing specialists

on site to deliver services, improving efforts to obtain reimbursements, 

and implementing prevention and wellness programs (see table 6 for the 

strategies and the number of facilities that reported using them). 

Table 6: Strategies to Increase Availability of Services Reported by 13 IHS-Funded 

Facilities 

Facilities Used a 

Variety of Strategies 

to Increase the 

Availability of 

Services 

Strategy Facilities reporting this strategy 

Brought specialists on site z

Improved efforts to obtain reimbursements z

Implemented prevention and wellness programs z

Negotiated discounts for contract care 

Coordinated patient care with other health services 

Increased use of telemedicine |

Source: GAO analysis of information reported by 13 IHS-funded facilities, as of June 2005. 

Legend:

z Reported by 9 to 13 facilities.

 Reported by 5 to 8 facilities.

| Reported by 1 to 4 facilities.

Facilities implemented these strategies in different ways. For example, to 

improve efforts to obtain reimbursements, four facilities had staff

available to help patients apply for eligibility or reimbursement from other

programs for which they were eligible. Others negotiated with state 

Page 29 GAO-05-789 Indian Health Service
Medicaid offices in order to be able to bill for services (see table 7 for a 

description of how facilities implemented the six strategies). 

Table 7: Description of How IHS-Funded Facilities Reported Implementing 

Strategies to Increase the Availability of Services 

Strategy Description 

Brought specialists 

on site 

• Used contract care funds to pay specialists to deliver services

on site. 

• Shared medical staff with other IHS-funded facilities to offer 

services not otherwise available on site. 

Improved efforts to

obtain 

reimbursements 

• Established partnerships with state Medicaid offices to facilitate 

enrollment in the program.

• Hired staff to help patients apply for non-IHS resources.

Implemented

prevention and 

wellness programs

• Obtained grants from IHS and other sources for a variety of

prevention and wellness programs. 

• Provided education and screenings targeted to health 

conditions prevalent among the patients served by the facilities, 

including diabetes, pregnancy, cancer, and heart disease. 

Negotiated discounts 

for contract care 

• Reached agreements with non-IHS hospitals and physicians 

for discounted rates for contract care. 

Coordinated patient

care with other 

health services

• Linked patients to other public or private health services—for 

example, services at Department of Veterans Affairs facilities—

that were not available through the facility. 

Increased use of

telemedicine 

• Supplemented imaging services by, for example, sending 

digital pictures of diabetics’ eyes to another IHS-funded facility 

to be read by an ophthalmologist. 

Source: GAO analysis of information from 13 IHS-funded facilities, as of June 2005. 

Some of the strategies were not available to, or effective for, every facility. 

For example, in one area that we visited, the area officials reported that 

facilities were not able to use contract care funds to bring in specialists 

unless they could provide assurances that they would be able to pay for all

emergent and acutely urgent care with remaining funds. One facility

stopped using contract care funds to bring in specialists because of that

policy. The effectiveness of another strategy was limited by the willingness 

of outside providers to negotiate contracts with the facility. For example, 

four facilities reported that while hospitals generally agreed to offer 

discounted rates for contract care, physicians were not always willing do 

so. Officials from two areas that we did not visit also reported that 

location had an impact on the effectiveness of some strategies. For some 

facilities in one of those areas, especially those in urban areas, it was 

difficult to retain billing staff needed to obtain reimbursements, because 

they could not match the private sector pay scale. 

Page 30 GAO-05-789 Indian Health Service
We provided a draft of this report for comment to the Director of the 

Indian Health Service. We received written comments from IHS. IHS

substantially agreed with the findings and conclusions of our report, but

did offer comments regarding examples used in our report, as well as 

comments on terminology and other technical issues. The full text of IHS’s

comments is reprinted in appendix III.

IHS questioned certain examples supporting our findings—one about the 

percentage of patients at one facility that went to the emergency room for 

delivery without receiving any prenatal care and two other examples 

about the effects of gaps in services. IHS recommended eliminating those 

examples if they could not be further substantiated. We reviewed the 

information supporting the examples. With regard to the level of prenatal

care, officials provided new information, which we incorporated into the

report. With regard to gaps in services, we determined that the examples

provided by tribal officials were consistent with the information about

service availability provided by officials at the facilities in question. 

IHS also provided us with comments on terminology and other technical

issues. With regard to terminology, IHS commented on our use of “Native 

Americans,” “contract care,” and “contract care area,” and requested that 

these terms be replaced with abbreviations or terms used by IHS. We did 

not alter our use of terms, but did include footnotes indicating IHS’s 

terminology. IHS’s technical comments related to funding for new IHS 

facilities, the effect of income demographics on Medicaid reimbursements, 

cardiovascular disease death rates for Native Americans, contract care 

priorities, and differences between IHS hospitals and health centers were 

incorporated as appropriate. In some cases, we did not make the changes 

IHS suggested because doing so would result in technical inaccuracies.

For example, we did not add “cardiovascular disease” to figure 1 as 

suggested by IHS because the figure highlights conditions for which 

mortality rates differ between Native Americans and the general

population—and cardiovascular disease mortality rates are virtually the 

same for both populations. 

As agreed with your offices, we plan no further distribution of this report

until 30 days from its date, unless you publicly announce its contents

earlier. At that time, we will send copies of this report to the Director of

the Indian Health Service. We will also make copies available to others

upon request. In addition, the report will be available at no charge on the 

GAO Web site at http://www.gao.gov. 

Agency Comments 

and Our Evaluation 

Page 31 GAO-05-789 Indian Health Service
If you or your staff have any questions about this report, please contact me

at (312) 220-7600 or aronovitzl@gao.gov. Contact points for our Offices of

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix IV. 

Leslie G. Aronovitz 

Director, Health Care

Page 32 GAO-05-789 Indian Health Service
Appendix I: GAO Methodology for Selecting Appendix I: GAO Me IHS Areas and Facilities Visited thodology for Selecting 

IHS Areas and Facilities Visited 

We used a two-tiered approach to selecting facilities for site visits, which 

included selecting 3 of the 12 Indian Health Service (IHS) areas and then 

selecting 13 facilities within those 3 areas. 

In the first tier, we selected 3 of the 12 IHS areas to represent a mix in the 

size of the population served in the areas, geographic location, health

status of Native Americans in the areas, the entities operating the facilities

(tribal or federal), and the contract care dollars as a percentage of total 

clinical care dollars (table 8 compares the selected areas to the range 

across all 12 areas). 

Table 8: Comparison of Three IHS Areas Selected by GAO to the Range across All 12 Areas 

IHS areas Factors 

considered 12 areas Aberdeen Oklahoma City Portland 

Estimated patients 

served (fiscal year

2004) 

From 24,009 in Tucson to

299,622 in Oklahoma City 

115,812 299,622 97,501

Age of patients 

(fiscal year 2001) 

• From 8.5% to 11.2% of 

the population under the 

age of 5 

• From 8.7% to13.3% over

the age of 54 

• 11.2% under the age 

of 5 

• 9.8% over the age 

of 54 

• 9.5% under the age

of 5 

• 13.3% over the age 

of 54 

• 9.1% under the age

of 5 

• 11.3% over the age 

of 54 

Birth rate (1996 to

1998) 

From 21.7 births per 1,000 

people in the service 

population to 29.5 per 1,000 

29.5 per 1,000 22.4 per 1,000 25.0 per 1,000 

Leading causes of 

death (1996 to 

1998) 

Heart disease (21.6%) 

Cancer (15.9%) 

Injuries (14.0%) 

Diabetes mellitus (6.6%) 

Liver disease and cirrhosis 

(4.5%)

Heart disease (21.1%) 

Cancer (15.0%) 

Injuries (14.4%) 

Diabetes mellitus (7.5%) 

Liver disease and 

cirrhosis (6.3%)

Heart disease (28.8%) 

Cancer (18.7%) 

Injuries (8.5%) 

Diabetes mellitus (7.0%) 

Cerebrovasular diseases

(4.6%)

Heart disease (19.4%) 

Cancer (15.6%) 

Injuries (14.7%) 

Cerebrovascular diseases 

(5.7%)

Liver disease and cirrhosis 

(5.6%)

Tribally operated

facilities (October 

2001) 

13 of 49 hospitals 

172 of 231 health centers 

84 of 133 health stations 

0 of 8 hospitals 

6 of 14 health centers 

3 of 15 health stations 

3 of 7 hospitals 

28 of 38 health centers 

(0 health stations in area) 

(0 hospitals in area) 

8 of 15 health centers 

28 of 28 health stations 

Contract care

dollars as a 

percentage of total 

clinical care dollars 

(fiscal year 2003) 

From 16% in Alaska to 

40% in Portland 

27% 19% 40%

Source: GAO summary of IHS and U.S. Census Bureau data. 

Page 33 GAO-05-789 Indian Health Service
Appendix I: GAO Methodology for Selecting 

IHS Areas and Facilities Visited

In the second tier, we selected facilities within the three areas. Facilities 

were selected to represent a mix in terms of the type of facility (for 

example, hospital or health center), whether it was tribally or federally 

operated, the size of its patient population, and whether the facility was 

located in a frontier or nonfrontier county (see table 9). The selected sites 

represent a mix of facility characteristics and populations served both

within and across the three areas. 

Table 9: Characteristics of 13 IHS-Funded Facilities Selected for Site Visits

Factors considered

Areas selected Facility type 

Operating 

body 

Location

(frontier or

nonfrontier

county)a

Estimated 

number of 

patients

served by 

facilityb

Aberdeen Hospital Federal Frontier 11,918

Hospital Federal Frontier 5,853

Health center Federal Frontier 3,596

Health center Federal Frontier 1,734

Oklahoma City Hospital Federal Nonfrontier 37,978

Hospital Tribal Nonfrontier Not availablec

Health center Federal Nonfrontier 8,993

Health center Tribal Nonfrontier Not availablec

Portland Health center Federal Frontier 8,490

Health center Federal Frontier 2,084

Health center Tribal Nonfrontier 3,950

Health center Tribal Nonfrontier 8,040

Health station Tribal Nonfrontier 111

Source: GAO summary of IHS headquarters and facility information. 

a

The Frontier Education Center designates a county as “frontier” based on a scoring system that

computes points based on a county’s population density, distance to the closest “market” for services,

and travel time to that market.

b

Based on IHS headquarters estimates for fiscal year 2004.

c

This facility is part of a group of tribally operated facilities for which IHS did not calculate patient

counts for each facility.

Page 34 GAO-05-789 Indian Health Service
Appendix II: GAO Methodology for Selecting Appendix II: GAO Methodology for Selecting Services 

Services 

We conducted semistructured interviews with each of the 13 facilities

visited to learn more about the availability of selected services. We 

selected these services using a two-step process—first, selecting a set of

health conditions reported to be prevalent among patients served by the 13 

facilities, and second, identifying diagnostic and treatment services that

are generally part of the standard course of treatment for each condition. 

To identify these services, we reviewed clinical standards published by 

IHS, medical associations, and other public entities, such as the 

Department of Health and Human Services’ Public Health Service. Table 

10 shows the 77 services selected for additional data collection.1

 1

Because of inconsistencies in how facilities responded, the data for 6 of the 77 services

were not used in the team’s analysis. 

Page 35 GAO-05-789 Indian Health Service
Appendix II: GAO Methodology for Selecting 

Services 

Table 10: Patient Condition and Services Selected, as of May 2005 

Patient condition Service 

Healthy • Medical services

• Blood lead levels (1 year) 

• Pap smear (>18 years) 

• Cholesterol level (men >35 years; women >45 years) 

• Mammography (>45 years) 

• Sigmoidoscopy (>50 years) 

• Thyroid function (>60 years) 

• Fasting glucose

• Tuberculosis screening 

• Iron deficiency screening 

Dental services 

• Emergency care 

• Prophylaxis (cleaning) 

• Sealants 

• Oral examination 

• Amalgam restoration 

• Cast inlays or crowns 

• Root canal 

• Dentures

• Periodontal surgery 

• Comprehensive orthodontics 

Vision services

• Eye examination–child 

• Eye examination–adult 

• Eyeglasses–child 

• Eyeglasses–adult 

• Elective contact lenses 

• Cataract surgery

• Urgent care (e.g., treatment of corneal abrasion) 

Head injury • Emergency medical services (ambulance) 

• Stabilization/emergency room care 

• Computerized tomography (CT) scan 

• Intensive care 

• Inpatient care

Page 36 GAO-05-789 Indian Health Service
Appendix II: GAO Methodology for Selecting 

Services 

Patient condition Service 

Type II diabetes • Physical examination

• Laboratory evaluation 

• A1C test

• Foot examination by specialist (high-risk patients) 

• Eye examination by specialist

• Test for lipid disorders 

• Nephropathy screening 

• Retinopathy screening 

• Medical nutrition therapy 

• Dialysis 

Pregnant • Initial physical 

• Initial laboratory assessment 

• Obstetrics–high-risk visit

• Obstetrics–high-risk follow-up visit 

• Amniocentesis (>35 years) 

• Ultrasound, second trimester 

• Vaginal delivery

• Cesarean section 

• Well-baby checkup 

Heart failure • History and physical examination 

• Initial laboratory assessment 

• Monitoring of serum electrolytes and renal functions 

• Electrocardiogram

• Echocardiography

• Cardiac catheterization 

• Angiotensin converting enzyme inhibitors, betablockers, and digitalis 

• Heart valve replacement or repair 

• Heart transplant 

Osteoarthritis of the knee • Analgesic/nonsteroidal anti-inflammatory drug

• Physical therapy 

• Durable medical equipment (e.g., braces and canes) 

• Radiographs 

• Arthroscopic debridement 

• Total knee arthroplasty 

Page 37 GAO-05-789 Indian Health Service
Appendix II: GAO Methodology for Selecting 

Services 

Patient condition Service 

Mental health disorder or

substance abuse 

• Emergency services

• Inpatient mental health care 

• Inpatient substance abuse treatment 

• Outpatient mental health care

• Outpatient substance abuse treatment 

• Psychotropic medication 

• Medication-assisted substance abuse treatment 

Colon cancer • CT scan of abdomen and pelvis

• Surgery

• Chemotherapy 

• Follow-up carcinoembryonic antigen tests (4 per year) 

• Supportive care 

Source: GAO analysis of clinical standards published by IHS, medical associations, and other public entities, as of June 2005. 

Page 38 GAO-05-789 Indian Health Service
Appendix III: Comments from the Indian Health Service Appendix III: Comments from the Indian 

Health Service 

Now on pp. 4, 5, and 23. 

Now on pp. 5 and 28. 

Now on p. 7. 

Page 39 GAO-05-789 Indian Health Service
Appendix III: Comments from the Indian Health Service 

Now on p. 11. 

Now on pp. 12 and 24. 

Now on p. 16. 

Now on p. 21. 

Now on pp. 22 and 23. 

Now on p. 24. 

Page 40 GAO-05-789 Indian Health Service
A

S

ppendix IV: GAO Contact and

taff Acknowledgments

Page 41 GAO-05-789

Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact Leslie Aronovitz (312) 220-7600 or aronovitzl@gao.gov

In addition to the contact named above, Carolyn Yocom, Assistant

Director; Susan Barnidge; Nancy Fasciano; and JoAnn Martinez-Shriver

made key contributions to this report.

Indian Health Service

Acknowledgments 

(290409)
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